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General NPI Number Information
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NPI Number | 1164973103
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Entity Type | Individual
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Provider Name | ARISTA GROOM LAT, ATC, EMT
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Gender | Female
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Dates
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Enumeration Date | 10/14/2016
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Last Update Date | 10/14/2016
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Provider Practice Location Address
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Address Line | 300 VIKING BLVD
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City | WINFIELD
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State | KS
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Zip | 67156-2508
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Country | US
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Telephone | 620-221-5160
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Fax |
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Provider Business Mailing Address
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Address Line | 1407 WHEAT RD
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City | WINFIELD
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State | KS
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Zip | 67156-4705
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Country | US
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Telephone | 620-221-5100
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 24-00777
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License Number State | KS
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